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WWW.IMGLOBAL.COM International Marine Medical Insurance SM S E R I E S A worldwide benefits program designed for groups of two or more professional marine captains and crew members
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International Marine Medical InsuranceSM
S E R I E S
A worldwide benefits program designed for groups of two or more professional marine captains and crew members
International Marine Medical InsuranceSM (IMMI)
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It’s rare to find an insurance provider that offers flexible, specialized products and associated services for the marine industry. Even rarer is to find a company with the dedication, resources, and ability to professionally administer healthcare benefits and deliver claims cost containment on a global basis. However, at International Medical Group® (IMG®), we understand the unique needs of marine crew professionals. In fact, we have an entire marine division dedicated to it.
Since 1990, our team has provided specialized insurance programs for captains, officers, and crew members. One such program is the International Marine Medical InsuranceSM
(IMMI) plan. This customizable plan offers medical coverage to groups of two or more marine crew professionals who live and work aboard ocean-going vessels.
The IMMI program, coupled with our expertise in marine claims, medical management, and international assistance services, will help you and your crew members properly prepare for injury or illness that occurs while on assignment. IMG provides more than just insurance; we provide the Global Peace of Mind® marine crew professionals deserve, backed by a team of professionals committed to being there when you need us.
Understanding your market.Exceeding your expectations.
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Maximum limit $5,000,000 per period of coverage
Benefit levelsUnited States United States International
In-Network Out-of-Network International
Deductible options $0 $100 - $10,000 $100 - $10,000
Deductible per familyMaximum three deductibles per family
$0 3 deductibles 3 deductibles
Deductible carry forwardExpenses incurred during the last three months of a calendar year will be applied toward satisfaction of the deductible for the next calendar year, but only if the deductible was not met during the prior calendar year.
CoinsuranceIn addition to deductible
Plan pays 100%, Member pays 0%
Plan pays 80%, Member pays 20%
Plan pays 100%, Member pays 0%
Out-of-pocket maximum $0 $1,000 $0
Medical ConciergeThe Medical Concierge Service (MCS) is a proprietary IMG service that helps our members navigate the U.S. healthcare system to identify the highest quality, most cost-effective providers for scheduled inpatient and certain outpatient treatments.
Pre-certification
• Transplants: No coverage if pre-certification requirements are not met
• Inter-facility Ambulance Transfer: No coverage if pre-certification requirements are not met
• Emergency Medical Evacuation: No coverage if pre-certification requirements are not met. Refer to the Emergency Medical Evacua-tion provision for further details and requirements
• Maternity and Newborn Care: 50% reduction of Eligible Medical Expenses if pre-certification requirements are not met
• All other treatments & supplies: 50% reduction of Eligible Medical Expenses if pre-certification requirements are not met
• Deductible is taken after the pre-certification reduction of benefits is applied
• Coinsurance is applied to remainder of the reduced amount
• Refer to Pre-certification Requirements provision for a complete list of services that require pre-certification
Pre-existing ConditionsSubject to deductible and coinsurance unless otherwise noted
Eligible medical expenses are limited to usual, reasonable, and customaryMaximum limits per calendar year, or, if indicated, per lifetime
Benefit In-Network Out-of-Network International
Sudden and Unexpected Reoccurrence of Pre-existing ConditionsUp to the calendar year maximum limit
100% 80% 100%
Medical Benefits Summary
All coverage and benefits in the plan are in United States (U.S.) dollars. Benefits are subject to the exclusions and limitations and are payable only at Usual, Reasonable and Customary charges. This is a summary of a selection of plan benefits offered only as an illustration and does not supersede in anyway the Certificate of Insurance and governing policy documents (together the “Insurance Contract”). The Insurance Contract is the only source of the actual benefits provided.
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Eligible Medical Expenses 100% 80% 100%
Physician Visits/Services 100% 80% 100%
Hospital Emergency Room: United States Injury: Not subject to Emergency Room Deductible
Illness: Subject to $250 deductible for each emergency room visit for treatment that does not result in a direct hospital admission
100% 80% 100%
Hospital Emergency Room: International
Hospitalization/Room & Board Average semi-private room rate. Includes nursing, miscellaneous, and ancillary services
100% 80% 100%
Intensive Care 100% 80% 100%
Outpatient Surgical/Hospital Facility 100% 80% 100%
Laboratory 100% 80% 100%
Radiology/X-rays 100% 80% 100%
Chemotherapy/Radiation Therapy 100% 80% 100%
Pre-admission Testing 100% 80% 100%
Surgery 100% 80% 100%
Reconstructive Surgery Surgery is incidental to and follows surgery that was covered under the plan
100% 80% 100%
Assistant Surgeon20% of the primary surgeon’s eligible fee
100% 80% 100%
Second Surgical OpinionPayable at 100% if requested by the company. 50% reduction of eligible medical expenses for failure to obtain a second surgical opinion when requested by the company
100% 80% 100%
Anesthetists 100% 80% 100%
Pregnancy & Newborn Care After 10 months of continuous coverage. Result of natural insemination. Newborn routine care, diagnostic tests, and routine immunizations for the first 31 days of life
100% 80% 100%
Pregnancy ComplicationsAfter 10 months of continuous coverage
100% 80% 100%
Durable Medical Equipment 100% 80% 100%
All coverage and benefits in the plan are in United States (U.S.) dollars. Benefits are subject to the exclusions and limitations and are payable only at Usual, Reasonable and Customary charges. This is a summary of a selection of plan benefits offered only as an illustration and does not supersede in anyway the Certificate of Insurance and governing policy documents (together the “Insurance Contract”). The Insurance Contract is the only source of the actual benefits provided.
Medical Benefits Summary (continued)
Inpatient or Outpatient Services Subject to deductible and coinsurance unless otherwise noted
Eligible medical expenses are limited to usual, reasonable, and customaryMaximum limits per calendar year, or, if indicated, per lifetime
Benefit In-Network Out-of-Network International
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Inpatient or Outpatient Services (continued)
Benefit In-Network Out-of-Network International
Podiatry CareMaximum limit: $750
100% 80% 100%
Chiropractic Care Not subject to deductible. Maximum limit per visit: $75. Maximum visits: 20. Physician order not required
50% 50% 50%
Chiropractic CareMust be part of a recovery treatment plan for a covered illness or injury. Medical order or treatment plan required
50% 50% 50%
Physical TherapyMaximum limit per visit: $75. Medical order or treatment plan required
100% 80% 100%
Extended Care FacilityUpon direct transfer from acute care facility 100% 80% 100%
Home Nursing CareProvided by a home healthcare agency. Upon direct transfer from an acute care facility
100% 80% 100%
TransplantLifetime maximum: $1,000,000. Per period of coverage transplant maximum limit: 1. Organ procurement and harvesting costs lifetime maximum: $10,000. Travel and lodging lifetime maximum expenses: $5,000. Covered transplants: cornea, heart, heart/lung, lung, kidney, kidney/pancreas, liver, allogeneic or autologous bone marrow. Subject to Transplant Pre-certification provision and only when treatment is provided within the company’s approved independent managed transplant system network
100% 80% 100%
Preventative Care NOT subject to deductible and coinsurance unless otherwise noted
Eligible medical expenses are limited to usual, reasonable, and customaryMaximum limits per calendar year, or, if indicated, per lifetime
Adult Preventative Care Ages 19 and over. Maximum limit: $250. Refer to the Preventative Care provision for further details and requirements
100% 100% 100%
Child Preventative Care Ages 18 and younger. Maximum limit: $250. Refer to the Preventative Care provision for further details and requirements
100% 100% 100%
Prescriptions Subject to deductible and coinsurance unless otherwise noted
Eligible medical expenses are limited to usual, reasonable, and customaryMaximum limits per calendar year, or, if indicated, per lifetime
PrescriptionsDispensing maximum: 90 days per prescription
80% 80% 100%
All coverage and benefits in the plan are in United States (U.S.) dollars. Benefits are subject to the exclusions and limitations and are payable only at Usual, Reasonable and Customary charges. This is a summary of a selection of plan benefits offered only as an illustration and does not supersede in anyway the Certificate of Insurance and governing policy documents (together the “Insurance Contract”). The Insurance Contract is the only source of the actual benefits provided.
Medical Benefits Summary (continued)
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Mental or Nervous, Substance Abuse, and Counseling Subject to deductible and coinsurance unless otherwise noted
Eligible medical expenses are limited to usual, reasonable, and customaryMaximum limits per calendar year, or, if indicated, per lifetime
Lifetime maximum $20,000
Inpatient Mental or Nervous /Substance Abuse Maximum limit: $10,000
100% 80% 100%
Outpatient Mental or Nervous/Substance Abuse Maximum limit per visit: $100. Maximum visits per calendar year: 52
50% 50% 50%
Emergency Services NOT subject to deductible and coinsurance unless otherwise noted
Eligible medical expenses are limited to usual, reasonable, and customaryMaximum limits per calendar year, or, if indicated, per lifetime
Emergency Local Ambulance Subject to deductible and coinsurance. Injury/illness resulting in an inpatient hospital admission
100% 80% 100%
Emergency Medical Evacuation Lifetime maximum: $1,000,000 for insured under age 65. Insured persons under 65 years of age. Approved in advance and coordinated by the company
100% 100% 100%
Emergency Reunion Lifetime maximum: $10,000. Maximum days: 15. Maximum meal limit per day: $25. Reasonable and necessary travel costs and accommodations. Approved in advance by the company
100% 100% 100%
Inter-facility Ambulance TransferTransfer must be the result of an inpatient hospital admission
100% 100% 100%
Return of Mortal Remains Maximum limit per insured person: $25,000. Local burial/cremation maximum limit: $10,000. Return of insured person’s mortal remains to home country. Approved in advance by the company
100% 100% 100%
Vision CareNOT subject to deductible and coinsurance unless otherwise noted
Eligible medical expenses are limited to usual, reasonable, and customaryMaximum limits per calendar year, or, if indicated, per lifetime
Routine Eye ExaminationAvailable after 12 months of continuous coverage
Maximum limit every 24 months: $100
Corrective Lenses, Contacts, FramesAvailable after 12 months of continuous coverage
Maximum limit every 24 months: $150
All coverage and benefits in the plan are in United States (U.S.) dollars. Benefits are subject to the exclusions and limitations and are payable only at Usual, Reasonable and Customary charges. This is a summary of a selection of plan benefits offered only as an illustration and does not supersede in anyway the Certificate of Insurance and governing policy documents (together the “Insurance Contract”). The Insurance Contract is the only source of the actual benefits provided.
Medical Benefits Summary (continued)
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Other Services NOT subject to deductible and coinsurance unless otherwise noted
Eligible medical expenses are limited to usual, reasonable, and customaryMaximum limits per calendar year, or, if indicated, per lifetime
Amateur Sailboat Racing Subject to deductible and coinsurance. Bodily injury as a result of an accident while participating in amateur sailboat racing
100% 80% 100%
Crew Member Return Maximum limit: $2,500
100% 100% 100%
Emergency Dental Subject to deductible and coinsurance. Accident-related
80% 80% 100%
Traumatic Dental InjuryTreatment at a hospital facility due to an accident. Additional treatment for the same injury rendered by a dental provider will be paid at 100%
100% 80% 100%
Hospital Indemnity International only. Benefit is not available when the inpatient hospital treatment is part of the medical travel management benefit. Inpatient hospitalization only
Not applicable Not applicableOvernight maximum limit: $100
Maximum overnight limit: 20
Maximum limit: $5,000
Medical Travel ManagementMust be approved in advance by the company
The company will offer medical travel as a means to manage the costs of medically necessary non-emergency treatment, including hospitalization and surgery for approved procedures. If medical travel is approved, the company will reimburse 10% of the cost savings, up to a maximum of $7,500 back to the insured person where such savings arise from treatment outside of the United States. Meal allowance maximum: $100. Refer to the Medical Travel Management provision for further details and requirements.
Non-Emergency Medical EvacuationLifetime maximum: $1,000,000. Insured persons under age 65. Approved in advance and coordinated by the company
100% 100% 100%
Recreational Underwater ActivitiesSubject to deductible and coinsurance. Injuries that occur while engaging in recreational underwater activities
100% 80% 100%
Supplemental Accident BenefitMaximum limit per covered accident: $300
100% 100% 100%
All coverage and benefits in the plan are in United States (U.S.) dollars. Benefits are subject to the exclusions and limitations and are payable only at Usual, Reasonable and Customary charges. This is a summary of a selection of plan benefits offered only as an illustration and does not supersede in anyway the Certificate of Insurance and governing policy documents (together the “Insurance Contract”). The Insurance Contract is the only source of the actual benefits provided.
Medical Benefits Summary (continued)
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Dental Benefits Summary
Coverage Limit/Maximum Amount for Eligible Dental Expenses
Calendar year maximum limit per person $1,500
DeductibleApplies to minor restorative, major restorative, and orthodontia services
$50
Family deductibleMaximum 3 deductibles per family
$150
Routine Services NOT subject to deductible and coinsurance unless otherwise noted
Eligible medical expenses are limited to usual, reasonable, and customaryMaximum limits per calendar year, or, if indicated, per lifetime
Benefit Coinsurance
Diagnostic and Preventative ServicesPreventative visits and cleanings: 2 (one every six months)Radiographic examinations (including posterior bitewings): 2 (one every six months). Fluoride treatment: 1 for children under age 19
Plan pays 100% Insured pays 0%
Emergency Palliative Treatment Plan pays 100% Insured pays 0%
Minor RestorativeSubject to deductible and coinsurance unless otherwise noted
Eligible medical expenses are limited to usual, reasonable, and customaryMaximum limits per calendar year, or, if indicated, per lifetime
RadiographsRadiograph: 1 every 3 years. Full mouth X-rays including panographic X-rays
Plan pays 80% Insured pays 20%
Oral Surgery Plan pays 80% Insured pays 20%
Endodontics Plan pays 80% Plan pays 20%
PeriodonticsRoot planing: 1 every 2 years Periodontal surgery: 1 every 3 years
Plan pays 80% Insured pays 20%
Minor Restorative ServicesRefer to the Eligible Dental Expenses provision forfurther details and requirements
Plan pays 80% Insured pays 20%
All coverage and benefits in the plan are in United States (U.S.) dollars. Benefits are subject to the exclusions and limitations and are payable only at Usual, Reasonable and Customary charges. This is a summary of a selection of plan benefits offered only as an illustration and does not supersede in anyway the Certificate of Insurance and governing policy documents (together the “Insurance Contract”). The Insurance Contract is the only source of the actual benefits provided.
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Group Life Insurance � Group Life benefit includes:
� Term Life Insurance Benefit � Accidental Death Benefit � Dismemberment Benefit
� 10 or fewer employees: � $10,000 minimum required
� Automatically approved up to $100,000 if member is approved for the IMMI medical plan
� Additional underwriting $100,001-$250,000
� Group Life can be issued as a flat amount (e.g. $50,000) or by salary (e.g. 2x salary)
� Group Life Reduction Schedule � Less than age 65: Full amount payable � Ages 65-69: 35% reduction � Ages 70-74: 55% reduction � Ages 75-79: 70% reduction � Age 80+: 80% reduction
Dental Benefits Summary (continued)
Major RestorativeSubject to deductible and coinsurance unless otherwise noted
Eligible medical expenses are limited to usual, reasonable, and customaryMaximum limits per calendar year, or, if indicated, per lifetime
Major Restorative ServicesCrowns, jackets, inlays (on same tooth): 1 every 5years. Limitations apply for children under age 12.Refer to the Eligible Dental Expenses provision forfurther details and requirements
Plan pays 50% Insured pays 50%
Prosthodontics Dentures/bridges: 1 every 5 yearsReplacement of denture base material or reline: 1 every 3 yearsRefer to the Eligible Dental Expenses provision for further details and requirements
Plan pays 50% Insured pays 50%
Orthodontia ServicesSubject to deductible and coinsurance unless otherwise noted
Eligible medical expenses are limited to usual, reasonable, and customaryMaximum limits per calendar year, or, if indicated, per lifetime
OrthodontiaChildren less than 19 years of age Plan pays 50% Insured pays 50%
All coverage and benefits in the plan are in United States (U.S.) dollars. Benefits are subject to the exclusions and limitations and are payable only at Usual, Reasonable and Customary charges. This is a summary of a selection of plan benefits offered only as an illustration and does not supersede in anyway the Certificate of Insurance and governing policy documents (together the “Insurance Contract”). The Insurance Contract is the only source of the actual benefits provided.
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International Marine Medical InsuranceSM (IMMI)
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Customizable Solutions
We are confident that IMMI will provide quality medical coverage specific to your organization’s and group members’ needs. For groups of a certain size, IMG offers the flexibility to customize benefits. Please contact your insurance producer for more information. Our reputation for excellence has been built on providing top-tier programs to organizations like yours around the world, and we will work closely with you to design a benefits package that meets your unique needs.
Medical Travel Management The Medical Travel Management benefit offers the member who is contemplating non-emergency medical treatment in the United States the opportunity to be financially compensated for having that care rendered by a qualified medical provider(s) outside of the U.S.
First, a designated nurse case manager will evaluate the cost effectiveness of an international medical travel case to assess whether the minimum savings required can be achieved as defined by the plan. The case manager will then assist the member in identifying a qualified medical provider to provide the specified care, while also negotiating medical fees. Upon approval, the case manager will coordinate the necessary services including patient care, travel, scheduling, and housing. The case manager will also assist with coordination of a medical follow-up visit upon returning home, when needed.
When treatment is received outside of the U.S. and there is cost savings greater than $10,000 to the plan, the member will personally share in any cost savings that are realized. The cost savings are calculated using the average U.S. cost of the medical service compared to the actual cost of the medical procedure and associated medical travel costs performed by the non-U.S.-based provider(s).
Medical Management Without Boundaries SM
The ability to access quality healthcare is essential when a medical emergency arises abroad. From routine medical care and check-ups, to complex case management and medical evacuations, IMG is there to offer our expertise and unique blend of services, including:
International Comprehensive Care ManagementCritically ill or injured crew have enough to worry about—let IMG ease the administrative workload and communications that come with complex international medical case management. Our experienced medical management team can assist with meeting the patient’s health and care needs to deliver the best possible outcome. Our medical staff will help coordinate care for your members who have highly complex cases requiring detailed management. These services may include assisting with:
� Concurrent review and monitoring of services for medical necessity
� Coordination of the hospitalization and any necessary post-discharge care
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P L A T I N U M Medical Benefits
Period of coverage Maximum limit: 365 days
Calendar year maximum limit Unlimited
Benefit levelsUnited States United States International
In-Network Out-of-Network International
Deductible options $0 $0 $0
Deductible per familyMaximum three deductibles per family
$0 $0 $0
Coinsurance Plan pays 100%, Member pays 0%
Plan pays 80%Member pays 20%
Plan pays 100%, Member pays 0%
Out-of-pocket maximum $0 $1,000 $0
Pre-certification
• Transplants: No coverage if pre-certification requirements are not met
• Inter-facility Ambulance Transfer: No coverage if pre-certification requirements are not met
• Emergency Medical Evacuation: No coverage if pre-certification requirements are not met. Refer to the Emergency Medical Evacua-tion provision for further details and requirements
• Maternity and Newborn Care: 50% reduction of Eligible Medical Expenses if pre-certification requirements are not met
• All other Treatments & supplies: 50% reduction of Eligible Medical Expenses if pre-certification requirements are not met
• Deductible is taken after reduction
• Coinsurance is applied to remainder of the reduced amount
• Refer to Pre-certification Requirements provision for a complete list of services that require pre-certification
Pre-existing Conditions
Pre-existing conditions are covered the same as any other illness or injury
All coverage and benefits in the plan are in United States (U.S.) dollars. Benefits are subject to the exclusions and limitations and are payable only at Usual, Reasonable and Customary charges. This is a summary of a selection of plan benefits offered only as an illustration and does not supersede in anyway the Certificate of Insurance and governing policy documents (together the “Insurance Contract”). The Insurance Contract is the only source of the actual benefits provided.
MyIMGSM Travel Intelligence & Member Tools
It’s easy to access and manage your IMG accounts any time, anywhere, from any device, via MyIMG. With MyIMG Travel Intelligence, you can get location-specific alerts across 10 threat categories that span health, transporation, security, and weather. Leverage location-specific travel intelligence like travel tips, tools, and key insights from local analysts.
Additional MyIMG features include:
� Claims submission and management � ID card and insurance documents access � Pre-certification process initiation � Explanation of Benefits (EOB) access � Customer Care live chat and contact information � Find a Doctor locator
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P L A T I N U M Medical Benefits (continued)
Inpatient or Outpatient Services Subject to deductible and coinsurance unless otherwise noted
Eligible medical expenses are limited to usual, reasonable, and customaryMaximum limits per calendar year, or, if indicated, per lifetime
Benefit In-Network Out-of-Network International
Eligible Medical Expenses 100% 80% 100%
Physician Visits/Services 100% 80% 100%
Hospital Emergency Room: United States Injury: Not subject to Emergency Room Deductible
Illness: Subject to $250 deductible for each emergency room visit for treatment that does not result in a direct hospital admission
100% 80% 100%
Hospital Emergency Room: International
Hospitalization/Room & Board Average semi-private room rate. Includes nursing, miscellaneous, and ancillary services
100% 80% 100%
Intensive Care 100% 80% 100%
Outpatient Surgical/Hospital Facility 100% 80% 100%
Laboratory 100% 80% 100%
Radiology/X-rays 100% 80% 100%
Chemotherapy/Radiation Therapy 100% 80% 100%
Pre-admission Testing 100% 80% 100%
Surgery 100% 80% 100%
Reconstructive Surgery Surgery is incidental to and follows surgery that was covered under the plan
100% 80% 100%
Assistant Surgeon20% of the primary surgeon’s eligible fee
100% 80% 100%
Second Surgical OpinionPayable at 100% if requested by the company. 50% reduction of eligible medical expenses for failure to obtain a second surgical opinion when requested by the company
100% 80% 100%
Anesthetists 100% 80% 100%
Pregnancy and Newborn CareAfter 10 months of continuous coverage. Result of natural insemination. Newborn routine care, diagnostic tests, and routine immunizations for the first 31 days of life
100% 80% 100%
Pregnancy ComplicationsAfter 10 months of continuous coverage
100% 80% 100%
Durable Medical Equipment 100% 80% 100%
Podiatry CareMaximum limit: $750
100% 80% 100%
All coverage and benefits in the plan are in United States (U.S.) dollars. Benefits are subject to the exclusions and limitations and are payable only at Usual, Reasonable and Customary charges. This is a summary of a selection of plan benefits offered only as an illustration and does not supersede in anyway the Certificate of Insurance and governing policy documents (together the “Insurance Contract”). The Insurance Contract is the only source of the actual benefits provided.
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P L A T I N U M Medical Benefits (continued)
Benefit In-Network Out-of-Network International
Chiropractic Care Not subject to deductible. Maximum limit per visit: $75. Maximum visits: 20. Physician order not required
50% 50% 50%
Chiropractic CareMust be part of a recovery treatment plan for a covered illness or injury. Medical order or treatment plan required
50% 50% 50%
Physical TherapyMaximum limit per visit: $75Medical order or treatment plan required
100% 80% 100%
Extended Care FacilityUpon direct transfer from acute care facility
100% 80% 100%
Home Nursing CareProvided by a home healthcare agency. Upon direct transfer from an acute care facility
100% 80% 100%
Transplant Lifetime maximum: $1,000,000. Per period of coverage transplant maximum limit: 1. Organ procurement and harvesting costs lifetime maximum: $10,000. Travel and lodging lifetime maximum expenses: $5,000. Covered transplants: cornea, heart, heart/lung, lung, kidney, kidney/pancreas, liver, allogeneic or autologous bone marrow. Subject to Transplant Pre-certification provision and only when treatment is provided within the company’s approved independent managed transplant system network.
100% 80% 100%
Preventative CareNOT subject to deductible and coinsurance unless otherwise noted
Eligible medical expenses are limited to usual, reasonable, and customaryMaximum limits per calendar year, or, if indicated, per lifetime
Adult Preventative Care Ages 19 and over. Maximum limit: $500. Refer to the Preventative Care provision for further details
100% 70% 100%
Child Preventative Care Ages 18 and younger. Maximum limit: $500. Refer to the Preventative Care provision for further details and requirements
100% 70% 100%
PrescriptionsSubject to deductible and coinsurance unless otherwise noted
Eligible medical expenses are limited to usual, reasonable, and customaryMaximum limits per calendar year, or, if indicated, per lifetime
United States Retail PharmacyNot subject to deductible and coinsuranceCopayments are per 30-day supplyDispensing maximum: 90 days per prescription
Universal Rx (URX) Prescription Drug Card MUST be utilized for all outpatient prescription drugs in the United States.
Retail Pharmacy Copayments: Generic: $5Higher-cost generic and brand: $15Non-preferred brand name: $30
International Prescriptions Dispensing maximum: 90 days per prescription
Coinsurance: 100%
International PrescriptionsCopayments are per 30-day supplyDispensing maximum: 180 days per prescription
Expatriate Prescription Services Program:Generic: $5Non-preferred brand name: $15Contact information: Enroll via the provider’s website www.expatps.comPrescription submission: Email (scan prescription): [email protected] or fax: +1.540.777.7184 Questions/concerns:Phone: +1.540.777.1450Email: [email protected]
All coverage and benefits in the plan are in United States (U.S.) dollars. Benefits are subject to the exclusions and limitations and are payable only at Usual, Reasonable and Customary charges. This is a summary of a selection of plan benefits offered only as an illustration and does not supersede in anyway the Certificate of Insurance and governing policy documents (together the “Insurance Contract”). The Insurance Contract is the only source of the actual benefits provided.
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Emergency ServicesNOT subject to deductible and coinsurance unless otherwise noted
Eligible medical expenses are limited to usual, reasonable, and customaryMaximum limits per calendar year, or, if indicated, per lifetime
Emergency Local Ambulance Subject to deductible and coinsurance Injury/illness resulting in an inpatient hospital admission
100% 80% 100%
Emergency Medical EvacuationLifetime maximum: $1,000,000 for insured under age 65 Insured persons under 65 years of ageApproved in advance and coordinated by the company
100% 100% 100%
Return of Mortal Remains Maximum limit per insured person: $25,000Local burial/cremation maximum limit: $10,000Return of insured person’s mortal remains to home country Approved in advance by the company
100% 100% 100%
Emergency Reunion Lifetime maximum: $10,000. Maximum days: 15. Maximum meal limit per day $25. Reasonable and necessary travel costs and accommodations. Approved in advance by the company
100% 100% 100%
Inter-facility Ambulance TransferTransfer must be the result of an inpatient hospital admission
100% 100% 100%
Mental or Nervous, Substance Abuse, and Counseling Subject to deductible and coinsurance unless otherwise noted
Eligible medical expenses are limited to usual, reasonable, and customaryMaximum limits per calendar year, or, if indicated, per lifetime
Lifetime Maximum $20,000
Inpatient Mental or Nervous/Substance Abuse Maximum limit: $10,000
100% 80% 100%
Outpatient Mental or Nervous/Substance Abuse Maximum limit per visit: $100. Maximum visits per calendar year: 52
50% 50% 50%
Vision Care Subject to deductible and coinsurance unless otherwise noted
Eligible medical expenses are limited to usual, reasonable, and customaryMaximum limits per calendar year, or, if indicated, per lifetime
Routine Eye ExaminationAvailable after 12 months of continuous coverage
Maximum limit every 24 months: $100
Corrective Lenses, Contacts, FramesAvailable after 12 months of continuous coverage
Maximum limit every 24 months: $150
Other ServicesNOT subject to deductible and coinsurance unless otherwise noted
Eligible medical expenses are limited to usual, reasonable, and customaryMaximum limits per calendar year, or, if indicated, per lifetime
Amateur Sailboat RacingSubject to deductible and coinsurance. Bodily injury as a result of an accident while participating in amateur sailboat racing
100% 80% 100%
Crew Member ReturnMaximum limit: $2,500 100% 100% 100%
Emergency DentalSubject to deductible and coinsurance. Accident-related
100% 100% 100%
Traumatic Dental InjuryTreatment at hospital facility due to an accident. Additional treatment for the same injury rendered by a dental provider will be paid at 100%
100% 80% 100%
P L A T I N U M Medical Benefits (continued)
All coverage and benefits in the plan are in United States (U.S.) dollars. Benefits are subject to the exclusions and limitations and are payable only at Usual, Reasonable and Customary charges. This is a summary of a selection of plan benefits offered only as an illustration and does not supersede in anyway the Certificate of Insurance and governing policy documents (together the “Insurance Contract”). The Insurance Contract is the only source of the actual benefits provided.
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Other Services (continued) NOT subject to deductible and coinsurance unless otherwise noted
Eligible medical expenses are limited to usual, reasonable, and customaryMaximum limits per calendar year, or, if indicated, per lifetime
Hospital IndemnityInternational only. Benefit is not available when the inpatient hospital treatment is part of the Medical Travel Management benefit. Inpatient hospitalization only
Overnight maximum limit: $50Maximum overnight limit: 20
Maximum limit: $1,000
Medical Travel ManagementMust be approved in advance by the company
Medically necessary non-emergency treatment, including hospitalization and surgery for approved procedures, the company will offer medical travel as a means to manage the costs. If medical travel is approved, the company will reimburse 10% of the cost savings, up to a maximum of $7,500 back to the insured person where such savings arise from treatment outside of the United States. Meal allowance maximum: $100. Refer to the Medical Travel Management provision for further details and requirements.
Non-Emergency Medical EvacuationLifetime maximum: $1,000,000. Insured persons under age 65. Approved in advance and coordinated by the company
100% 100% 100%
Recreational Underwater ActivitiesSubject to deductible and coinsurance. Injuries that occur while engaging in recreational underwater activities
100% 80% 100%
Supplemental Accident BenefitMaximum limit covered per accident: $500
100% 100% 100%
Coverage Limit/Maximum Amount for Eligible Dental Expenses
Calendar year maximum limit $1,500
DeductibleApplies to minor restorative, major restorative, and orthodontia services
$50
Family deductibleMaximum 3 deductibles per family
$150
Dental Benefits Summary
Routine Services NOT subject to deductible and coinsurance unless otherwise noted
Eligible medical expenses are limited to usual, reasonable, and customaryMaximum limits per calendar year, or, if indicated, per lifetime
Benefit Coinsurance
Diagnostic and Preventative ServicesPreventative visits and cleanings: 2 (one every six months)Radiographic examinations (including posterior bitewings): 2 (one every six months)Fluoride treatment: 1 for children under age 19
Plan pays 100% Insured pays 0%
Emergency Palliative Treatment Plan pays 100% Insured pays 0%
P L A T I N U M Medical Benefits (continued)
All coverage and benefits in the plan are in United States (U.S.) dollars. Benefits are subject to the exclusions and limitations and are payable only at Usual, Reasonable and Customary charges. This is a summary of a selection of plan benefits offered only as an illustration and does not supersede in anyway the Certificate of Insurance and governing policy documents (together the “Insurance Contract”). The Insurance Contract is the only source of the actual benefits provided.
International Marine Medical InsuranceSM (IMMI)
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W W W . I M G L O B A L . C O M
Minor RestorativeSubject to deductible and coinsurance unless otherwise noted
Eligible medical expenses are limited to usual, reasonable, and customaryMaximum limits per calendar year, or, if indicated, per lifetime
RadiographsRadiograph: 1 every 3 years. Full mouth X-rays including panographic X-rays
Plan pays 80% Insured pays 20%
Oral Surgery Plan pays 80% Insured pays 20%
Endodontics Plan pays 80% Plan pays 20%
PeriodonticsRoot planing: 1 every 2 years Periodontal surgery: 1 every 3 years
Plan pays 80% Insured pays 20%
Minor Restorative ServicesRefer to the Eligible Dental Expenses provision forfurther details and requirements
Plan pays 80% Insured pays 20%
Major RestorativeSubject to deductible and coinsurance unless otherwise noted
Eligible medical expenses are limited to usual, reasonable, and customaryMaximum limits per calendar year, or, if indicated, per lifetime
Major Restorative ServicesCrowns, jackets, inlays (on same tooth): 1 every 5years. Limitations apply for children under age 12.Refer to the Eligible Dental Expenses provision forfurther details and requirements
Plan pays 50% Insured pays 50%
Prosthodontics Dentures/bridges: 1 every 5 yearsReplacement of denture base material or reline: 1 every 3 yearsRefer to the Eligible Dental Expenses provision for further details and requirements
Plan pays 50% Insured pays 50%
Orthodontia ServicesSubject to deductible and coinsurance unless otherwise noted
Eligible medical expenses are limited to usual, reasonable, and customaryMaximum limits per calendar year, or, if indicated, per lifetime
OrthodontiaChildren less than 19 years of age Plan pays 50% Insured pays 50%
P L A T I N U M Medical Benefits (continued)
All coverage and benefits in the plan are in United States (U.S.) dollars. Benefits are subject to the exclusions and limitations and are payable only at Usual, Reasonable and Customary charges. This is a summary of a selection of plan benefits offered only as an illustration and does not supersede in anyway the Certificate of Insurance and governing policy documents (together the “Insurance Contract”). The Insurance Contract is the only source of the actual benefits provided.
International Marine Medical InsuranceSM (IMMI)
19
W W W . I M G L O B A L . C O M
P.O. Box 88509Indianapolis, IN 46208-0509 USA
Telephone: 1.317.655.4500 or 1.866.368.3724Fax: 1.317.655.4505
Email: [email protected]
I M G P R O D U C E R U S E O N L Y
0319CM00500702A190514
W W W . I M G L O B A L . C O M
